PEMERINTAH DAERAH PROVINSI JAWA BARAT

DINAS PENDIDIKAN
Jalan Dr. Radjiman No. 6 Telp. (022) 4264813 Fax. (022) 4264881
Website : disdik.jabarprov.go.id
e-mail: disdik@jabarprov.go.id/sekretariatdisdikjabar@gmail.com
BANDUNG - 40171

BIODATA PESERTA
LOMBA KOMPETENSI SISWA (LKS) SMK
TINGKAT PROVINSI JAWA BARAT
TAHUN 2023

KABUPATEN/KOTA : ....................................................
BIDANG LOMBA : ....................................................

1. Nama Lengkap : ..................................................................................

2. NIS / NISN : ...................................../............................................
3. Tempat/Tanggal Lahir : ..................................................................................
4. Jenis Kelamin : Laki-laki/Perempuan*)
5. Agama : ..................................................................................
6. Program Studi Keahlian : ..................................................................................
7. Kelas : ..................................................................................
8. Asal Sekolah : ..................................................................................
9. Alamat Sekolah : ..................................................................................

..................................................................................
Kab./Kota*) .........................................
Tlp. ( .......... ) ........................ Fax. ...........................
10. Alamat Rumah : ..................................................................................
Desa/Kel*) ................................................................

Pas Photo
Kecamatan ...............................................................
(Berwarna) No. Tlp. (......) ...................... HP. .............................
E-mail : .................................................................
3x4

Mengetahui : ..............................., ................... 2023

Kepala SMK .................................................
..................................................................... Peserta,

( .................................................................) ( ....................................................)
NIP. .......................................................

Catatan : - Diisi dengan huruf kapital

- *) coret yang tidak perlu